Provider Demographics
NPI:1770866444
Name:LIGHTHOUSE PHYSICIAN SERVICES, PLLC
Entity Type:Organization
Organization Name:LIGHTHOUSE PHYSICIAN SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RADIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENODIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-252-7447
Mailing Address - Street 1:427 TRACE WAY DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77316-6852
Mailing Address - Country:US
Mailing Address - Phone:936-463-8777
Mailing Address - Fax:603-658-0484
Practice Address - Street 1:427 TRACE WAY DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77316-6852
Practice Address - Country:US
Practice Address - Phone:936-463-8777
Practice Address - Fax:603-658-0484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN93532085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty